Conceptual framework: Culture is a major factor in end-of-life decision-making. Rural-urban cultural differences are likely to be reflected in the use of medical services near the end of life. Overview: This research will test three hypotheses addressing (1) lower use of six medical services near the end of life in rural areas when compared with urban areas, (2) lower use of these services in farming rural areas when compared with nonfarming rural areas, and (3) greater rural-urban differences in the use of end-of-life services than in the use of services two years prior to death. Methods: The study population will be comprised of approximately 16,953 individuals who were MN and TX nursing home residents with severe cognitive impairment in 1999-2000 and who subsequently died. The hypotheses will be tested by linking data on (a) clinical and functional status from the Minimum Data Set (MDS), (b) medical service utilization from Center for Medicare and Medicaid Services (CMS) and administrative data, (c) date of death from the CMS Denominator file, and facility characteristics from OSCAR data. The location of nursing homes will be determined using facility codes from the MDS linked to county codes and to metro-nonmetro, continuum codes. The dependent variables to be examined are (1) feeding tube use, (2) IV medication use, (3) hospital admissions, (4) hospital days, (5) hospital claims, and (6) ICU days. Data from MDS, MedPAR and Hospice files will be used to test hypotheses, using hierarchical linear modeling. SIGNIFICANCE: This research is part of a series of research efforts designed to contribute to improvement in end-of-life care for all elders, through improving understanding of regional and cultural variation in end-of-life goals, values and practices.